Postpartum hemorrhage is one important cause of maternal mortality and morbidity. In developed countries, postpartum bleeding is the third most frequent cause of maternal mortality, and in the United Kingdom is responsible for one death for each 100,000 live births. The incidence is higher in less developed countries, and in Zimbabwe postpartum bleeding is the cause of 40 maternal deaths for each 100,000 births. It is clear that methods of treating and preventing postpartum hemorrhage will have a significant impact in reducing maternal mortality and morbidity.
We report a series of cases involving women with uterine atony and actual postpartum bleeding who were successfully treated by placing compressive sutures around the uterus.
MATERIALS AND METHODS
Seven women with uterine atony and postpartum hemorrhage were treated with compressive sutures of the uterus. In all cases, the procedure was performed after failure of medical treatment. Before the procedure was attempted, all patients were treated with continuous oxytocin perfusion (40 U in 1,000 mL normal saline at 200 mL/h) for 10 minutes; if they did not respond to treatment, they were given an additional continuous sulprostone (a synthetic prostaglandin estradiol analogue) infusion (500 μg in 250 mL normal saline at 17 mL/min) for another 15 minutes.
There were 3 cases of hemorrhage secondary to uterine atony. These patients were given packed red blood cell transfusions and the procedure was performed to stop the hemorrhage. In the other 4 cases, the diagnosis of uterine atony with early hemorrhage was made during cesarean delivery and more bleeding was therefore prevented. These last cases did not require any transfusion of blood derivatives.
The patients' demographic characteristics, diagnoses, and results of treatment are shown in Table 1.
The compressive/hemostatic sutures consisted of a series of transverse and longitudinal sutures of multifilament absorbable Vicryl 1 placed around the uterus (Figure 1). Placement of the sutures involved a series of bites inserted superficially, taking only the serous membrane and the subserous myometrium without penetrating the uterine cavity (Figure 2). Two or three transverse circular sutures were placed first, starting in the anterior aspect of the uterus, crossing the broad ligament toward the posterior aspect of the uterus, then crossing the opposite broad ligament toward the anterior aspect and tying the suture over the anterior aspect of the uterus (Figure 3). The number of bites in the uterus varied according to the size of the organ. When the suture crossed the broad ligament, it was important to select an avascular area and to be sure that the fallopian tube, the uteroovarian ligament, and the round ligament were not inside the suture (Figure 1). The last transverse circular suture in the lower uterine segment served as an anchor for 2 or 3 longitudinal sutures. Each longitudinal suture started on the dorsal side of the uterus using a knot to fix it to the lowest circular suture (Figure 4) and ended on the ventral side using another knot attached to the lowest transverse suture (Figure 5). When each myometrial suture was placed, manual compression was applied to the uterus to achieve maximum reduction of uterine volume before tying the suture. The final result of the method is shown in Figure 6.
The mean time required to complete the procedure was 5 minutes (range 4–7 minutes).
Postpartum uterine bleeding stopped immediately after application of the compressive/hemostatic sutures. None of the patients developed complications related to the procedure, and menstrual cycles resumed in all women without problems. One woman became pregnant again and had a repeat cesarean delivery at 38 weeks without complications or problems.
According to Pritchard et al,1 the average blood loss during vaginal and cesarean delivery is 500 mL and 1,000 mL, respectively. Based on this study, many clinicians consider that there is postpartum hemorrhage when the blood loss is greater than these values.
In practice, the amount of blood lost during delivery is estimated subjectively, and the severity of bleeding is frequently underestimated. When a decrease of 10% or more in hematocrit or the need for transfusion is used as an index of the severity of bleeding, postpartum hemorrhage occurs in 3.9% of vaginal and 6.4% of cesarean deliveries.2,3
Postpartum hemorrhage is classified as “early” when it occurs in the first 24 hours after delivery and as “late” when it occurs from 24 hours to 6 weeks postpartum. Early postpartum hemorrhage comprises 80% of all cases, the main cause being uterine atony.
Several methods have been described for the treatment of postpartum hemorrhage secondary to uterine atony, including mechanical (uterine compression, uterine packing, Foley balloon or condom inflated with water inside the uterine cavity) and pharmacologic (oxytocin, methylergonovine, prostaglandins) methods. If bleeding persists after the pharmacologic and mechanical methods have been tried, the surgical approaches are uterine artery ligation, hypogastric artery ligation, or hysterectomy, the last of these being the treatment of choice. Clark et al4 report that 43% of their emergency postpartum hysterectomies are performed because of intractable uterine atony. In our hospital, over a 10-year period involving 36,032 deliveries, we have performed 30 postpartum hysterectomies because of bleeding secondary to uterine atony. All surgical treatments of postpartum bleeding have significant morbidity and are not always effective.
Christopher B-Lynch et al5 have described a highly effective surgical technique for the control of postpartum bleeding: compressing the uterus with 2 longitudinal sutures along its long axis and preventing the uterus from relaxing and filling with blood. In their technique, the uterine cavity is penetrated with the sutures. Our method offers theoretical advantages to their technique. Each of our sutures is made up of a succession of small bites of the uterus, distributing the pressure of the suture more evenly and making compression more effective. The suture does not penetrate the endometrial cavity, thus decreasing the risk of infection. The small size of the bites applied to the uterus reduces the risk of a loop of bowel or the risk of the omentum coming between the uterus and the suture with puerperal involution. Finally, the combination of longitudinal and transverse sutures not only aids compression but also collapses the lumen of ascending branches of the uterine artery, reducing vascular flow and venous bleeding.
The main limitation of our study is the small number of cases. Further studies are necessary to obtain full proof of the effectiveness and lack of complications of this technique.
1.Pritchard JA, Baldwin RM, Dickey JC, Wiggins KM. Blood volume changes in pregnancy and the puerperium: II. Red blood cell loss and changes in apparent blood volume during and following vaginal delivery, caesarean section, and caesarean section plus total hysterectomy. Am J Obstet Gynecol 1962;84:1271–82.
2.Combs CA, Murphy EL, Laros RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76.
3.Combs CA, Murphy EL, Laros RK. Factors associated with postpartum hemorrhage in caesarean deliveries. Obstet Gynecol 1991;77:77–82.
4.Clark SL, Yeth SY, Phelan JP, Bruce S, Paul RH. Emergency hysterectomy for obstetric haemorrhage. Obstet Gynecol 1984;64:376–80.
5.Christopher B-Lynch, Coker A, Laval AH, Abu J, Cowen MJ. The B-Lynch surgical technique for control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–6.